- Coroner finds inadequate funding, unsafe staffing and neglect contributed to baby’s death
- Trust says safe staffing for neonatal services “unrealistic challenge” with current funding levels and workforce shortages
- Report sent to outstanding trust where the death occurred and NHS England’s specialised commissioning group
Inadequate funding and unsafe staffing at an outstanding trust contributed to the death of a baby girl last winter, a coroner has found.
In a report to prevent future deaths, a coroner found an intensive neonatal unit at Birmingham Women’s Hospital was not safely staffed when caring for a prematurely born baby, Kiarah Faith Adora Allen, in February this year.
The hospital is run by Birmingham Women’s and Children’s Foundation Trust, which is rated outstanding and lead by Sarah-Jane Marsh, who also chairs NHS England’s maternity transformation programme.
Responding to the report, the trust’s chief nursing officer Michelle McLoughlin told HSJ it was an “unrealistic challenge” to meet safe neonatal staffing levels with the “given the funding available to deliver the service and the supply of neonatal nurses”.
She said: “Nevertheless, it was very clear from our own internal investigation that the level of nurse staffing on the day of this sad incident fell below what we would consider to be an acceptable standard.”
The report was sent to both the trust and the neonatal critical care clinical reference group at NHS England, which is responsible for funding neonatal services nationally.
Birmingham and Solihull senior coroner Louise Hunt said at the time the unit was only funded for nurses to deal with 85 per cent occupancy, a figure that was exceeded on the day of Kiarah’s death.
“At the time this incident occurred there were unsafe levels of nursing and clinical staff,” she said.
“Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for.”
Baby Kiarah was born on 9 February and died two days later in the neonatal unit, after she was mistakenly overloaded with fluid.
“Kiarah died from an inadvertent fluid overload… as a result of unsafe staffing levels, not correctly following the procedure and failing to learn from a previous similar event. Her death was contributed to by neglect,” the report said.
The coroner heard that Kiarah was being fed a nutritional supplement through a tube, which was in the process of being switched.
However, during the switchover one of the two junior nurses involved was called away and the other nurse inadvertently left both the old and the new tube attached.
The child died soon after.
The coroner also said the trust has “failed to learn from previous similar incidents”.
Ms McLoughlin said other factors included communication and escalation failures at the unit.
Since Kiarah’s death the unit’s leadership had been strengthened and a better mix of staffing skills introduced, she said.
“We are truly sorry and we have expressed our heartfelt apologies to her family that let we let them down at the time their precious daughter needed us most.”
NHS England have been approached for comment.
Prevention of future deaths report